Conflict, Displacement and Living with a Chronic Disease Inside View 12/12/2022 • Éimhín Ansbro, Grace Dubois, Nicolai Haugaard, Peter Klansø & Micaela Serafini Share this:Click to share on Twitter (Opens in new window)Click to share on LinkedIn (Opens in new window)Click to share on Facebook (Opens in new window)Click to print (Opens in new window) Two women walk through the streets of Aleppo, an ancient Syrian city reduced to rubble by war. On the occasion of Universal Health Coverage Day, thought leaders on the front lines outline the challenges and opportunities of health systems in conflicts. The last decade of 12-year-old Zaynab’s life has been spent in an informal settlement in Lebanon, after her family fled from the Syrian conflict. She shares a three-room tent with her parents, grandparents and six siblings. Since leaving Syria, Zaynab has been diagnosed with type 1 diabetes and controlling her blood sugar level requires taking insulin several times a day. Zaynab is not the only one in her family with a long-term health condition – her father and grandmother are living with type 2 diabetes. Managing an NCD like diabetes is tough for any child – but for Zaynab and her family, buying insulin and blood sugar testing strips has been an ongoing challenge. She and her family members have often delayed, reduced, or completely missed out on treatment because of the cost. For people living with type 1 diabetes, their life depends on sustained access to insulin – a century old drug that remains costly and hard to access in many settings like Zaynab’s refugee camp. Conflict, health emergencies and the climate crisis continue to impact lives across the world, with an estimated 103 million displaced persons in 2022. The conflict in Ukraine has driven one of the largest exodus of people since World War II and it remains, alongside Syria, one of the largest refugee and displacement crises of our time. However, those crises are only the tip of the iceberg. Eight out of every ten displaced persons live in low- and middle-income countries, where people are also disproportionately at risk of premature death from chronic, or noncommunicable, diseases (NCDs). When a humanitarian emergency strikes, many people affected or forced to flee live with pre-existing chronic health conditions that are exacerbated by the accompanying stress and difficulties in accessing scarce or disrupted medical care. Persons living with a chronic disease, including those with hypertension and type 2 diabetes – the most common among Syrian refugees – are more vulnerable in humanitarian emergencies, as they need continuous access to essential health services, including affordable and available medicines and testing equipment adapted to crisis settings and climate extremes. Care that leaves no one behind Zaynab’s father doesn’t have regular work, and her mother earns less than the cost of feeding the family a simple diet of potatoes and pulses. As one of several humanitarian agencies operating in Lebanon, the International Committee of the Red Cross (ICRC) has stepped in to guarantee the family’s medicines and supplies, including Zaynab’s life-saving insulin treatments. However, the family still faces the expense of buying healthy food and challenges in applying other medical recommendations, such as regular physical activity. If the world is to achieve universal health coverage (UHC) – in which no one is left behind – finding solutions to challenges faced by individuals like Zaynab and her family must form part of the discussion. Recent years have seen increased attention to address the specific challenges of people living with NCDs in humanitarian settings. World Health Organization (WHO) Member States, for example, have adopted the NCD Compact to protect the lives of 1.7 billion people living with NCDs the world over by 2030, including during humanitarian emergencies. For that to happen will require strong leadership, reliable data and an efficient multi-disciplinary and multi-stakeholder approach. While operational considerations proposed by a set of humanitarian agencies around NCD prevention and care in humanitarian settings are yet to be widely implemented in the way HIV/AIDS guidelines for humanitarian settings have been, encouraging progress is being made.. A new set of recommendations on the issue was approved by WHO Member States at the World Health Assembly earlier this year and it is hoped there will also be progress made on the issue through a series of WHO meetings on the topic in 2023 as well as through next year´s UN High-Level Meeting on UHC. The path towards universal health coverage An ‘informal tented settlement’ in Lebanon’s Bekaa valley. The mountains in the background form the border with Syria, just a few miles away. Fundamentally, all countries need to be working towards achieving UHC, including countries impacted by humanitarian crises. Lebanon for example is a country of fewer than seven million inhabitants and is hosting nearly one million registered Syrian refugees. This has increased the country’s population by 15%, placing enormous pressure on its infrastructure, including the health system. All efforts towards achieving UHC must include the integration of NCD services into community services and primary health care (PHC) facilities to ensure people living with NCDs have access to quality services across the continuum of care, and avoid the need for costly and time-consuming travel to distant hospitals and overburdening secondary and tertiary care. Local nurses and community health workers are indispensable: with appropriate training, they can manage many conditions in collaboration with primary care doctors, facilitate referrals, and support continuum of care and adherence to treatment. Increasingly, people live with more than one health condition: for instance, hypertension, diabetes and mental health conditions are often interlinked. Person-centred care building care around the person and their family, their needs and perspectives can be achieved through an integrated service approach. People living with NCDs usually require care throughout their lives, including regular follow-up to prevent long-term complications, such as diabetic foot ulcers or terminal kidney failure. Therefore, they need to be empowered to manage their health, to engage proactively with and help shape health services, and incorporate treatment into daily life and make the healthiest possible choices. Person-centred care in humanitarian crises The smoke of the Beirut harbour explosion spreads over the skies of Lebanon. In their journey to seek safe new homes, many displaced persons find themselves in countries with their own set of problems and challenges. To ensure person-centred care during situations of displacement, the continuum of care must be protected. Authorities could explore the option of providing information about possible access points to be consulted during a person’s onward journey. Alternatively, individuals could be offered larger quantities of medication and care supplies to cover periods where it will be difficult to access a health facility, as well as information on self-management of their conditions, including clear guidance on any red flags that signal the need to seek in-person medical care. Building a bank of evidence-based research would help us understand how to best improve care for people living with NCDs under very challenging circumstances. Also, the private sector could and should play a larger role when it comes to identifying solutions that meet the needs of people with NCDs affected by humanitarian crises. Finally, the importance of community support for displaced people and those living in humanitarian crises – both practically and emotionally – cannot be overemphasized. In Zaynab’s family for example, there are in fact now three people living with diabetes; they support one another in adhering to treatment plans, and in self-care. Supporting families and peers to manage healthcare in their own communities may improve more self-reliance, while also giving them a greater sense of stability, empowerment and purpose. Overcoming the challenges faced by people living with NCDs under very difficult conditions extends far beyond access to medication. It is about how health systems under serious stress can be strengthened to provide continued, affordable access to NCD prevention and treatment. Until this is achieved for the most vulnerable groups of people, including those living in humanitarian settings, there can be no Universal Health Coverage. About the authors Éimhín Ansbro is the Deputy Director of Centre for Global Chronic Conditions and NCD in Humanitarian Settings Special Interest Group Lead at the London School of Health and Tropical Medicine. Micaela Serafini is the Head of Health Unit at the International Committee of the Red Cross. Nicolai Haugaard is the Vice President and Global Head of Access to Care at Novo Nordisk. Peter Klansø is the Director of International Department at the Danish Red Cross. Grace Dubois is the Policy & Research Manager for the NCD Alliance. Image Credits: UK DFID. 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